Volume 105, Issue 4 (June 2006)

Editorials

When it became apparent that there was going to be a paucity of voluntarily submitted articles relating to the theme of “Ethical Issues,” we contacted 3 respected medical ethicists in the region with the request that they write briefly on topics of current interest to each of them. The resulting papers are, we hope, of high interest to readers.

Commentaries

The subject of medical ethics has long been part of preparing medical students for their duties as professionals and educating them about the ethical issues they will face. Traditionally, students have learned part of medical ethics by observing their professional role models in clinical care. Students have also been instructed more formally through statements of medical ethics by the American Medical Association’s (AMA’s) Code of Ethics, which was first enacted in 1847 and has since been expanded in biennial editions.1 The Hippocratic Oath, emphasizing such principles as confidentiality and acting solely for the benefit of patients, was incorporated into medical school education, and the majority of medical schools’ graduating classes recited the oath during graduation ceremonies.

If the amount of newspaper space devoted to an issue reflected its importance, then the most important issue facing America right now is whether or not there should be an asterisk after Barry Bonds’ name in the baseball record books. It wasn’t always that way. Prior to September 11, 2001, the press was consumed with the question of whether President Bush would or should allow federal funds to be used for research using human embryonic stem cells. At the time, the overriding moral issue seemed to be a debate about the moral status of the embryo.

Patient demographics are changing, not only in Wisconsin1 but throughout the Midwest and the entire United States. In the past, one talked about religious and racial diversity, but now the issues become more complex with cultural diversity. The ethnic or cultural diversity in Wisconsin has grown impressively. Diversity is no longer limited to “white American,” “African American,” or “Native American.” It now includes Asian, Eastern European, Sub?Saharan African, and Middle Eastern countries. Also, many states are experiencing considerable growth in their Latino populations.

Original Research

Background: In 1989, experts in cancer prevention, early detection, and treatment met in Madison to set the public health agenda for cancer control. Part of the plan defined target percent change in cancer mortality rates to be met by the year 2000. During the 1990s, public health and health care professionals developed programs and policies to reach these goals. The purpose of this analysis is to evaluate Wisconsin’s progress in reducing cancer mortality and success in meeting the year 2000 objectives.

Methods: Wisconsin mortality data for 1984-1986 and 1999-2001 were obtained from the Centers for Disease Control and Prevention, CDC Wonder. Percent change was calculated between the 2 time periods and compared to the 2000 target percent change for all-site cancer and site specific cancer mortality.

Results: All-site cancer mortality decreased by 7% from 1984-1986 to 1999-2001 with a greater than 16% decline in age groups <65 years. Mortality from breast, colorectal, and cervical cancer each decreased by at least 25%. Lung cancer and malignant melanoma mortality rates increased by 5% and 17%, respectively. Among additionally analyzed cancers, mortality decreased in prostate, stomach, and childhood cancers and increased in liver cancer and non-Hodgkin’s lymphoma.
Conclusion: The results of the state’s cancer control effort are mixed. The year 2000 objectives were met for breast and colorectal cancer. Progress was made in reducing mortality from cervical cancer and from all sites combined, but the other year 2000 objectives were not met. Mortality rates increased for lung cancer and malignant melanoma during the 15-year period.
Neil J. Hoxie, MS; Matthew J. Maxwell, BS; Wendy Schell, MS; William J. Reiser, MSN, RN; James M. Vergeront, MDPrenatal HIV Testing in Wisconsin: Results of a Survey Among Women Who Gave Birth in 2003
(full text PDF)

Since 1995 the United States Public Health Service has recommended voluntary prenatal human immunodeficiency virus (HIV) testing for all pregnant women in the United States. To better understand how well this goal is being met in Wisconsin, the Wisconsin Division of Public Health facilitated a review of hospital medical records for a random sample of women who gave birth in Wisconsin in 2003. Of the 968 maternal medical records reviewed, 68% (95% CI: 65%-71%) showed evidence that the mother had a completed HIV antibody test during pregnancy. Rates of prenatal HIV testing were higher in Milwaukee County. After controlling for residence, prenatal HIV testing rates were higher among Hispanic mothers compared to white mothers; African American and white mothers had similar testing rates. These data suggest that the goal of voluntary HIV testing for all pregnant women is not currently being met in Wisconsin.

Ischemic preconditioning is a physiologic phenomenon that occurs in the cardiac muscle in which brief episodes of ischemia protect the heart when exposed to a sustained ischemia. Clinical counterparts include potential benefits of preinfarction angina and less ischemia after a second, compared to a first, coronary angioplasty balloon inflation. This article will discuss how preconditioning might be applied to the clinical setting during acute myocardial infarction, coronary interventions, and cardiac surgery.

Background: Reimbursement obstacles, such as inadequate insurance coverage, have been identified as barriers to adequate pain management. The purpose of this study was to determine Wisconsin insurers’ and managed care organizations’ (MCOs) policies and practices regarding pain treatment and MCO medical directors’ perceptions of barriers to providing effective pain management for their enrollees.

Methods: A descriptive qualitative design was used with semi-structured interviews of 6 administrative executives of commercial health management organizations’ products from the major insurers in Wisconsin.

Results: None of the companies interviewed had systematically tracked data or had processes in place to allow them to track, analyze or trend data specific to pain management. Chronic noncancer pain is recognized more frequently as an insurance coverage issue because of high drug costs. Pharmacologic and interventional therapies are routinely covered compared with nonpharmacologic therapies with some prior authorizations, especially for newer medications. A uniformly identified barrier was lack of a comprehensive, interdisciplinary, integrated approach to pain management and inadequate data on the cost effectiveness of various approaches.

Conclusions: Opportunities exist to educate and improve communication between health care professionals, purchasers of health care (employers), primary care providers and pain specialists. The economics of pain management needs to be made more “visible” through the development of coding and tracking mechanisms.

Case Reports

Purpose: We describe a patient presenting with a vascular mass of the lower lip with a history of traumatic lip-biting. The lesion was treated with preoperative intravascular embolic therapy and surgical excision.

Summary: Arteriovenous fistula (AVF) of the head and neck are vascular lesions with a single connection between the involved artery and vein. Trauma to the area, often in the distant past, is often seen as the inciting event. We describe a patient with a lower-lip AVF with repeated episodes of lip biting that caused expansion of the mass. The patient underwent preoperative embolic therapy and surgical excision with excellent functional and cosmetic outcome.

Conclusion: Arteriovenous fistula of the lower lip can be successfully managed with preservation of lip function and cosmesis through combined intravascular and surgical therapy.

Herein is reported a case of a putative tumor of the left adrenal gland found incidentally during the workup of a cirrhotic patient with portal hypertension. This mass manifested vascular enhancement and other features of an adenoma both on computed tomography (CT) and magnetic resonance imaging (MRI) scans. Additional workup revealed elevated salivary cortisol and plasma aldosterone levels. A proposed biopsy of this mass was deferred because of an episode of variceal bleeding that required placement of a transjugular intrahepatic portosystemic shunt (TIPS). Post TIPS placement, repeat CT and MRI scans showed that the mass had disappeared, indicating that this pseudotumor was, in fact, a knot of peri-adrenal varices, which was now decompressed. In this report, the anatomic and pathologic basis of peri-adrenal varices in a patient with portal hypertension is discussed, as well as the ability of current imaging studies at establishing this diagnosis. Liver disease may cause abnormalities in endocrine function, which make this diagnosis difficult.

Your Practice

Health care professionals should not underestimate the importance of assuring that potential and current employees, contractors, and vendors are not considered excluded providers for purposes of federal health care reimbursement programs (including Medicare and Medicaid). Excluded providers have been convicted of fraud and abuse related to federal health care programs pursuant to the Exclusion Program administered by the Office of Inspector General (OIG), which prohibits excluded providers from receiving Medicare or Medicaid payments for items and services that they furnish. Although the potential penalties for inadequate screening can be significant, the burden of conducting the screening is diminutive.

In January 2006, the Centers for Medicare and Medicaid Services (CMS) launched the Physician Voluntary Reporting Program (PVRP). Under this program, physicians who choose to participate will help capture data about the quality of care provided to Medicare beneficiaries.

A controversial ruling enacted earlier this year by the US Securities and Exchange Commission muddies the distinction between financial planners and stockbrokers, further confounding investors who are seeking unbiased financial advice.

Your Profession

As the end of my time as dean of the University of Wisconsin (UW) School of Medicine and Public Health quickly draws to a close, I wanted to take a moment to thank the leadership of the Wisconsin Medical Society for its ongoing support. In fact, without the Society’s enthusiastic endorsement nearly 100 years ago, the school might not be celebrating its centennial next year. Personally, I am also grateful to the Society for the wonderful opportunity it’s given me in this Wisconsin Medical Journal Dean’s column.

Edited by Kesavan Kutty, MD, FACP, Chapter GovernorProceedings from the 2004 Annual Meeting of the American College of Physicians, Wisconsin Chapter, Part 2
(full text PDF)

The Wisconsin Chapter of the American College of Physicians held its annual meeting in Waukesha, Wis, September 9-11, 2004. Internal Medicine residents from each of Wisconsin’s 5 residency programs (Gundersen Lutheran Health System, Marshfield Clinic, The Medical College of Wisconsin, University of Wisconsin Hospital and Clinics, and University of Wisconsin Milwaukee Clinical Campus [Aurora Sinai Medical Center]) presented their research and/or unusual clinical experiences via posters and vignettes. On behalf of the Chapter, it is my pleasure to provide the text versions of their presentations, in an attempt to not only showcase the scholarly work of these physicians-in-training, but also to provide Wisconsin Medical Journal readers an overview of the quality of care given by them in the fine residency programs in our state. Finally, although these minimally edited Proceedings are by themselves very educational, being there to listen to them live is, indeed, priceless. On behalf of our Chapter, I invite you to witness this unique experience at our next Chapter meeting, September 7-8, 2006, at the Milwaukee Marriott West, Waukesha, Wis. (Editor’s note: This is the second half of 2004’s Proceedings. The first half was published in our previous issue: WMJ 105 #3.)

Walther Meyer, MDObesity—What we are doing isn’t working! What can we blame?
(full text PDF)

The following paragraph is taken from a recent ‘Team Nutrition’ pamphlet from the US Department of Agriculture: “The US Department of Agri-culture (USDA) is doing what it can to help. The National School Lunch and School Breakfast Programs must be consistent with the Dietary Guidelines for Americans. USDA’s Team Nutrition Initiative provides nutrition education materials to help schools meet these standards.” President Bush urged all school districts to develop a plan for combating childhood obesity and to have this plan ready for school year 2006. The problem of childhood obesity has been growing for years and has not responded to previous attempts to control this urgent problem. It has finally become severe enough to demand presidential attention to validate that this is indeed a national problem and needs immediate attention.

Your Society

The theme of this issue of the Wisconsin Medical Journal is ethics. So perhaps it is fitting that this is the last issue for which Doctor Meyer will serve as Medical Editor. He is a man with many wonderful qualities: intelligence, affability, dedication, wit and, most certainly, integrity.